Debra L. Roter

Meta-analysis of correlates of provider behavior in medical encounters.

This article summarizes the results of 41 independent studies containing correlates of objectively measured provider behaviors in medical encounters. Provider behaviors were grouped a priori into the process categories of information giving, questions, competence, partnership building, and socioemotional behavior. Total amount of communication was also included. All correlations between variables within these categories and external variables (patient outcome variables or patient and provider background variables) were extracted. The most frequently occurring outcome variables were satisfaction, recall, and compliance, and the most frequently occurring background variables were the patients gender, age, and social class. Average correlations and combined significance levels were calculated for each combination of process category and external variable. Results showed significant relations of small to moderate average magnitude between these external variables and almost all of the provider behavior categories. A theory of provider-patient reciprocation is proposed to account for the pattern of results.

The Roter interaction analysis system (RIAS): Utility and flexibility for analysis of medical interactions

The Roter interaction analysis system (RIAS), a method for coding medical dialogue, is widely used in the US and Europe and has been applied to medical exchanges in Asia, Africa, and Latin America. Contributing to its rapid dissemination and adoption is the systems ability to provide reasonable depth, sensitivity, and breadth while maintaining practicality, functional specificity, flexibility, reliability, and predictive validity to a variety of patient and provider outcomes. The purpose of this essay is two-fold. First, to broadly overview the RIAS and to present key capabilities and coding conventions, and secondly to address the extent to which the RIAS is consistent with, or complementary to, linguistic-based techniques of communication analysis.

The enduring and evolving nature of the patient–physician relationship

Just as the molecular and chemistry oriented sciences were adopted as the 20th century medical paradigm, incorporation of the patients perspective into a relationship-centered medical paradigm has been suggested as appropriate for the 21st century. It is the medical dialogue that provides the fundamental vehicle through which the paradigmatic battle of perspectives is waged and the therapeutic relationship is defined. In many regards, the primary challenge to the field is the development of operationally defined and measurable indicators of medical communication that will provide a valid representation of the conceptual models of the therapeutic relationship. The purpose of this essay is to explore the implications of a relationship-centered medical paradigm on the nature of the patient-physician relationship and its expression in the communication of routine medical practice. An organizing framework for distinguishing commonly measured communication elements into conceptually distinct components is suggested. Application of this framework is illustrated through an empirical study of communication in primary care practice. The results of the study demonstrate the usefulness of this approach in linking communication to models of therapeutic relationships. The importance of medical communication is further explored in a summary of studies that establish its association to outcomes and in an overview of future challenges to the field.

Gender in medical encounters: An analysis of physician and patient communication in a primary care setting.

The relation of physician and patient gender to verbal and nonverbal communication was examined in 100 routine medical visits. Female physicians conducted longer visits, made more positive statements, made more partnership statements, asked more questions, made more back-channel responses, and smiled and nodded more. Patients made more partnership statements and gave more medical information to female physicians. The combinations of female physician-female patient and female physician-male patient received special attention in planned contrasts. These combinations showed distinctive patterns of physician and patient behavior, especially in nonverbal communication. We discuss the relation of the results to gender differences in nonclinical settings, role strains in medical visits, and current trends in medical education.

Patient adherence to HIV medication regimens: A review of published and abstract reports

A literature search was conducted to collect published articles reporting correlates of HIV medication adherence or interventions designed to increase HIV medication adherence. Proceedings from seven HIV/AIDS-related conferences were searched for relevant abstracts. We found 18 descriptive studies in published articles and 57 in conference proceedings producing over 200 separate variables falling into four broad areas: (1) factors related to treatment regimen; (2) social and psychological factors; (3) institutional resources; and (4) personal attributes. More complex regimens were related to decreased adherence, but were often successfully mitigated by regimen aids. Social and psychological factors reflecting emotional adjustment to HIV/AIDS and provider support were related to adherence. Access to institutional resources was associated with better adherence. Personal attributes showed a mixed relationship; gender was not consistently related to adherence, but younger age, minority status, and a history of substance abuse were often related to non-adherence. The intervention search yielded 16 interventions employing a wide range of behavioral, cognitive and affective strategies. Evidence of effectiveness was weak. We conclude the abstracts are a useful source of information as part of a systematic review, particularly when available published literature is limited, if results and study characteristics are reported in an adequate and standard manner.

The expression of emotion through nonverbal behavior in medical visits. Mechanisms and outcomes.

Relationship-centered care reflects both knowing and feeling: the knowledge that physician and patient bring from their respective domains of expertise, and the physician’s and patient’s experience, expression, and perception of emotions during the medical encounter. These processes are conveyed and reciprocated in the care process through verbal and nonverbal communication. We suggest that the emotional context of care is especially related to nonverbal communication and that emotion-related communication skills, including sending and receiving nonverbal messages and emotional self-awareness, are critical elements of high-quality care. Although nonverbal behavior has received far less study than other care processes, the current review argues that it holds significance for the therapeutic relationship and influences important outcomes including satisfaction, adherence, and clinical outcomes of care.

The effects of two continuing medical education programs on communication skills of practicing primary care physicians

AbstractPurpose: To evaluate and compare the effects of two types of continuing medical education (CME) programs on the communication skills of practicing primary care physicians. Participants: Fifty-three community-based general internists and family practitioners practicing in the Portland, Oregon, metropolitan area and 473 of their patients. Method: For the short program (a 4 1/2-hour workshop), 31 physicians were randomized to either the intervention or the control group. In the long program (a 2 1/2-day course), 20 physicians participated with no randomization. A research assistant visited all physicians’ offices both one month before and one month after the CME program and audiotaped five sequential visits each time. Data were based on analysis of the content and the affect of the interviews, using the Roter Interactional Analysis Scheme. Results: Based on both t-test analysis and analysis of covariance, no effect on communication was evident from the short program. The physicians enrolled in the long program asked more open-ended questions, more frequently asked patients’ opinions, and gave more biomedical information than did the physicians in the short program. Patients of the physicians who attended the long program tended to disclose more biomedical and psychosocial information to their physicians. In addition, there was a decrease in negative affect for both patient and physician, and patients tended to demonstrate fewer signs of outward distress during the visit. Conclusion: This study demonstrates some potentially important changes in physicians’ and patients’ communication after a 2 1/2-day CME program. The changes demonstrated in both content and affect may have important influences on both biologic outcome and physician and patient satisfaction.

Patient-physician communication: A descriptive summary of the literature

Abstract This paper summarizes the results of 61 independent studies containing descriptive variables from objectively measured medical encounters. Over 200 unique patient and provider variables were identified and grouped a priori, through a process of consensual validation, into six broad categories of communication process variables: information-giving, information-seeking, partnership-building, social conversation, positive talk and negative talk. Length of medical visit and proportionate contribution of each speaker were abstracted. In addition each study was coded for 47 study attributes including characteristics of the sample, study design and methodology. Study results fall in three broad areas: (1) characteristics of the studies are presented based on the coded attributes; (2) communication profiles of patient and physician interaction are constructed by averaging the data over studies; and (3) comparisons of communication behavior across studies are presented by common sample and setting characteristics.

Do patients talk differently to male and female physicians? A meta-analytic review

A meta-analytic review was undertaken of seven observational studies which investigated the relation between physician gender and patient communication in medical visits. In five of the studies the physicians were in general practice, internal medicine, or family practice and were seeing general medical patients, and in two of the studies the physicians were in obstetrics-gynecology and were seeing women for obstetrical or gynecological care. Significant findings revealed that, overall, patients spoke more to female physicians than to male physicians, disclosed more biomedical and psychosocial information, and made more positive statements to female physicians. Patients also were rated as more assertive toward female physicians and tended to interrupt them more. Several results were weaker, or even reversed, in the two obstetrics-gynecology studies. Partnership statements were made significantly more often to female than male physicians in general medical visits but not in obstetrical-gynecological visits.

Physicians’ psychosocial beliefs correlate with their patient communication skills

AbstractOBJECTIVE: To assess the relationship between physicians’ beliefs about the psychosocial aspects of patient care and their routine communication with patients. PARTICIPANTS AND SETTING: Fifty community primary care physicians participating in a continuing medical education program and 473 of their patients in Portland, Oregon. METHODS: Routine office visits were audiotaped and analyzed for communication behaviors and emotional tone using the Roter Interactional Analysis System (RIAS). Physician beliefs about psychosocial aspects of care were measured using a self-report questionnaire with a five-point Likert scale. Attitudes were correlated with communication behaviors using the Pearson correlation coefficient. RESULTS: Physicians’ attitudes toward psychosocial aspects of care were associated with both physician and patient dialogue in visits. The physicians who had positive attitudes used more statements of emotion (i.e., empathy, reassurance) (p<0.05) and fewer closed-ended questions (p<0.01) than did their colleagues who had less positive attitudes. The patients of the physicians who had positive attitudes more actively participated in care (i.e., expressing opinions, asking questions), and these physicians provided relatively more psychosocial and less biomedical information (p<0.05). CONCLUSION: Physician beliefs about psychosocial aspects of patient care are associated with their communication with patients in routine office visits. Patients of physicians with more positive attitudes have more psychosocial discussions in visits than do patients of physicians with less positive attitudes. They also appear more involved as partners in their care. These findings have implications for medical educators, teachers, and practicing physicians.